A number of 26 policy makers, academics, and experts in public health and PHC participated in this study, of whom 24 men and 2 women with an average age of 45 years participated. The work experience of participants was between five and twenty years old with an average of 12.7 years. The education level of the participants varied from lower diploma to PhD.
Data analysis according to the building blocks framework, illustrated the current state of the PHC in Iran in six main themes and 21 sub themes, with a total of 1,440 extracted codes. Table 2 indicates the extracted themes and sub-themes.
1. Leadership and governance
The participants expressed the positive effects of the PHC such as having a service provision base in all parts of the country, having the capacity to integrate new health care programs, low cost and effectiveness of services to attract health officials’ attention. In addition, they emphasized the involvement of people, charities, and intergovernmental organizations in advancing the goals of the PHC and stated that the private sector was not observed in the structure and had no flexibility structure to adapt to the changes. Furthermore, the authority to change the structure was not delegated to regional managers.
“The current structure of the primary healthcare system is fixed. We have established a health house for a population of 1500 people. Now, the population has migrated and we have kept the health house. We need to move the organizational chart without any concern and set up the base in the places we need." (Provincial health center expert)
The working hours of service providers are not in line with the working and living conditions of the people who are not free to choose the place to receive the service that has eliminated the competition. With the global and local changes in epidemiology and changing needs, the PHC has no ability to provide new services with the current structure and respond to new needs of people.
"New problems with cardiovascular disease, accidents, cancers, diabetes in urban areas are also greater, but our system is active in villages for women and children. In fact, we are not accountable".Health policy maker
According to the participants the policy makers' have more focused on the curative activities in compare to public health and PHC activities. Decisions are made as centralized and often are not evidence-based. Parallel systems are created in the health system while there is no appropriate interaction between service provider's levels (preventive, specialized and ultra-specialized) and overlapping is observed in the provision of services. Having a holistic view is a priority in the health system. Implementations of the programs are dependent to the managers and policy makers who are changing frequently. Academic and clinical departments and institutions are unfamiliar with public health and preventive issues.. Even, the factors out of health area such as political and economic factors influence the management of PHC network system.
"I suggest that university management posts should be at a clinical level, while we should use those with a degree in health education who have studied the system and are skilled in the system.")Expert of the University of Medical Sciences)
The lack of attention to the principle of community participation and the non- use of the charitable capacity as well as the failure to attract cooperation and the use of capacity of organizations which are directly related to health are among the main challenges.
"In our primary healthcare system, the participation of people has been neglected. Firstly, we have not been trained to participate with the people and the way of participation is not clear". (Expert of the Ministry of Health)
The participants believed that some reforms should be applied to the PHC structure according to the changes and new needs. The explanation of government in PHC is reduced. Health experts should be used in health management by use of the participation of people, charities, and intergovernmental organizations.
2. Health care financing
Participants stated that in addition to the lack of resources and sustainability of PHC funds, inappropriate financial planning for the public health sector has made it to be more vulnerable than other areas of health at the shortage of resources.
“Financial resources are one of the blind spots we have. The health system has no sustainable resources and such resources contribute less to the primary healthcare”. Provincial health center expert
Despite the growth of service costs, the place of insurance in PHC structure is unclear. Public health services have not been priced rationally and the distribution of unfair resources leads to more health resources in the field of treatment.
"Distribution of resources is unfair when we study justice in health distribution and we say that we have access to a quarter of services in the capital city of Tehran. Look at the prices in Ilam (North West City of Iran)? "Expert of the Ministry of Health
Providing public health services is costly, and some cost-effective services are not available. For example, maintaining a health-care home in low-income areas. In the discussion of outsourcing of services because of the lack of requirements and a comprehensive model, assigning services to the private sector would be difficult.
"We are stingy in outsourcing. The government wants all workers and the employers and the supervisor. It is clear that the business will not go well." (National level Health expert)
Participants believed that some sustainable resources should be observed for the PHC. Proportionate budget services should be allocated to integrate and complete the services. If resources distribute equitably, the public health sector's share of health resources will increase. By designing an appropriate outsourcing pattern, the private sector's capacity can be used to deliver services.
3. Medical products and technology
Participants stated that the use of new medications and new technologies is unreasonable. Personnel are unfamiliar with the technology. With the introduction of new technologies, people's attention to health care has diminished. New technologies are not used in the PHC and diagnostic and therapeutic technologies are not evaluated in terms of health conditions and their health impact.
"New technologies were used indiscriminately without evaluating the effectiveness, efficiency, and safety of the country and the public's attention to prevention programs has reduced. It seems that everyone is looking for the action with early results." Faculty of the University of Medical Sciences
Public and PHC health centers are not equipped for new services.
"Public health homes have no possibility of providing new care because the control of most current illnesses is the presence of a laboratory, and public health centers are not fully equipped" Chief of the city health center
Participants concluded that new products and technologies should be evaluated. In addition, they believed that appropriate technologies at the PHC should be used and the standard equipment of public health homes and re-evaluated centers should be re-equipped.
4. Health information system
Participants stated that integrated health systems (so called SIB) and electronic health records are in the early stages. The personnel are not familiar with how these systems work. The integrated health system is not aligned with the priorities of the PHC system. However, the requirements for using the systems are not fully prepared. There is no relationship between the systems.
"The requirements for the deployment of this system including the Internet, telephone, staff skills, the beliefs of physicians in the system and the integrity of managers in the establishment of the system have not yet been realized." Expert of the University of Medical Sciences
No certainty exists about the accuracy of the output statistics and information, and there is no coherent and consistent information system at the PHC.
"Information technology has not found its place in provision. We do not know about the accuracy of information even in the number of the population. We have problems in data and consequently in information and knowledge production". Health policy maker
Participants believed that the health management information system should be established in the area of public health and PHC. The personnel should be taught about how to work with systems. The systems should be customer-oriented and a link should be crated between the systems.
5. Health workforce
Participants mentioned the effects of native selection among health workers and they stated that the living conditions in the villages are not affordable and, the payment system is unfair and is not based on performance. No specific mechanism exists for personnel upgrading and transferring which led to a downturn in the motivation of the PHC personnel. In addition, a change in the level of literacy and livelihoods led to a decline in the acceptance of health workers and a reduction in their relationship with people. In urban areas, health care providers are unaware of the population due to the large and frequent changes in the population.
The shortage and poor distribution of human resources, especially in rural and suburban areas aggravates the problem in this area. In some locations, the duties were imposed on public health staff more than they can. Despite the presence of university graduates in most regions, there is no mechanism for using them. The authority to organize personnel was not delegated to regional managers.
"There are the same organizational posts and we still have El Tor expert. How many times El Tor can happen in a year?”Provincial health center expert
The universities of medical sciences do not coordinate with the PHC and the medical education system is not tailored to the needs while the educational content is not evident. As a result, university graduates are not familiar with the problems and have no enough skills to deal with.
"The training offered in the university is not according to the tasks that the individual will perform in the system, and the content of the training varies with the implementation". City health center expert
Inappropriate strategy for attracting health workers with low education is still in progress. Health worker education is not updated and unmatched with new needs and services. During the past years, the improvement of health workers was not considered and their level of literacy was lower than the average of the society.
"Our health workers were educated for the 1980 and 1990s, so they are not accountable in the current situations. Their educators lack high literacy and cannot adapt themselves to the modern knowledge." Expert of the Ministry of Health
Participants believed that a fair payment system should be established among providers, a mechanism should be designed for the transfer and maintenance of personnel, the required human resources should be provided before adding new services, the authority to revise the organization chart should be assigned to spatial planning lands, and the medical education system and content should be updated to fit the needs. The attraction of health workers should be based on well-educated college graduates and health faculties (professors-facilities) to train health workers.
6. Providing health services
Participants referred to the qualitative growth and diversity of the primary healthcare services and the good practices implemented by the FP and the health promotion plan in the health area (building health complexes-improving urban services provision and marginalized population care). In addition, the participants noted that the influence of some people caused deviations in health transformation plan, and the same routine programs were implemented as part of a health change plan. Then, the issue of disease prevention was faded by pushing more people towards curative activities.
“Some people affected the health development plan. We did not have an environmental health, and health education before the development plan?” Health policy maker
The inappropriate design of service leveling has led to a long and complex path. Specialized levels are not obliged to adhere to the leveling. Policy makers and people do not seek to establish a referral system. FPs is unfamiliar with the program goals and focuses more on quantity. Health team members do not interact well. Therapeutic physicians have no ability to act as FPs for preventive programs. A physician receives the full per capita for the covered population and the survival or sickness of population does not affect his payment while people pay for specialized treatment costs.
"The FP we have is defective. The physician graduates from the university with a therapeutic vision and does not engage in active health care at all and does not show interest" senior health insurance staff
Existing capacities (audio and video) are not used for improving the community health literacy, there is not enough education available to people, and community members are not empowered and do placing no role in the healthcare. Providing primary healthcare services is concentrated in rural areas and is unsuccessful in urban areas. Services offered to men are weaker than women. The services provided at primary healthcare are at an advanced level and there is no defined complementary service to meet the needs of the population in the current situation.
Participants believed that we should empower the community and individuals to do some services themselves while demanding the government the services. Providing services at the context of FP and health complexes should continue. Paying salaries based on providing health care to the health care team creates a greater sense of responsibility towards the health of the people and Electronic referencing system is being implemented by forcing people and specialized levels. The service provision and service content should change based on the needs and plan to provide complementary services at the PHC centers.